Blank form assembly



April 1967 R. A. ROBERTSON BLANK FORM ASSEMBLY Filed May 16, 1966 2 mw o Mm am. v- \l A m. M ms s s F R m R mm D M R R R R 0 0 O N .0 N C m E M M 2 3 FIGZ nNU

S T m T w E I A D R A H B ATTORNEYS United States Patent 3,315,984 BLANK FORM ASSEMBLY Richard A. Robertson, Detroit, Mich., assignor to Van Richards Company, Detroit, Mich. Filed May 16, 1966, Ser. No. 550,528 7 Claims. c1. 282-22 This invention relates to multiple copy blank form assemblies and more particularly to a multiple copy medication order form for a hospital patient.

It is an object of the invention to improve the utility of multiple copy order form assemblies by providing such an assembly having a face sheet sectioned for multiple orders, a backing sheet joined to the face sheet along one edge, tabs formed along another edge of the two sheets and which are separable from the two sheets by a snapping action so that duplicate sheets interjacent the face sheet and the backing sheet and joined to the tabs may be removed from the assembly by said snapping action.

It is another object of the present invention to improve hospital patient medication order forms by providing such a form having a face sheet on which the physican may prescribe a plurality of medication orders, and including a set of separate duplicate sheets associated with each order and which are physically separated from the duplicate sheets associated with any other order.

Still further objects, advantages and applications of the present invention will become apparent to one skilled in the art to which the invention pertains upon reference to the following detailed description of the preferred embodiment of the invention and to the accompanying drawings in which like reference characters refer to like parts throughout the several views and in which FIG. 1 depicts a medication order form assembly illustrating a preferred embodiment of the present invention with parts cut away for purposes of clarity;

FIG. 2 is a sectional view of the assembly as seen from lines 2-2 of FIG. 1; and

FIG. 3 illustrates the separation of one of the sets of duplicate sheets from the order form assembly.

Referring to the drawings, FIG. 1 illustrates a preferred medication order form assembly as preferably comprising a unitary sheet doubled along a fold line to form a face sheet 12 and a backing sheet 14. The sheets 12 and 14 preferably have a rectangular outline with the fold line 10 formed along a long side. The sheets 12 and 14 are formed of a paper having a weight sufiicient to withstand relatively severe handling. The fold line 10 is perforated so that the face sheet .12 may be separated from the backing sheet 14. A pair of apertures 16 are formed along the upper short side of the sheets 12 and 14 to assist the user in inserting the blank form assembly in .a conventional chart holder (not shown).

The lower portion of the face sheet 12 is divided into three similar order sections 1 8. Each of the order sections has printed matter relating to the medication order and also blank spaces to be filled in with special matter associated with a particular patient for Whom the order is prescribed by the physician. It is to be understood, of course, the face sheet 12 is illustrated with three order sections 18 for purposes of description only, and that any practical number of order sections may be provided as is desired.

A tab 20 is associated with each of the order sections 18 and forms an extension of the face sheet 12 on the side opposite the fold line 10. The tabs 20 are separate from one another and may be individually separated from the face sheet 12 along a perforated line 22.

Referring to FIG. 3, the backing sheet 14 is provided with tabs 24, each of which is associated with a tab 20 and which forms an extension of the backing sheet on the side opposite the fold line 10. Each of the tabs 24 may be separated from the backing sheet along a perforated line 26 which coincides with the perforated lines 22 on the face sheet.

As can best be seen in FIGS. 1 and 3, a duplicate form set 28 is associated with each of the order sections 18 and for purposes of illustration comprises three duplicate order copies 30. The duplicate order copies 30 are formed of a material characterized by the property that it produces visible indicia when subjected to pressure. Each of the duplicate form sets 28 underlies an order section 18 so that when a pressure such as that produced by a ball point pen or a typewriter key or the like is imposed on the face sheet 12, indicia corresponding to the impression or writing on the face sheet will be produced on each of the order copies 30.

Normally the physician will write his prescription on the face sheet 12 in one of the order sections 18 which is normally considered as the original and which is maintained as a permanent part of the patients record. The duplicate order copies 30 are distributed to interested parties such as the pharmacy, the business office, and a medication file. Thus the duplicate order copies preferably have substantially the identical printed matter imposed thereon with the exception of the printed matter defining the distribution of the particular copy. The duplicate order copies are also preferably color coded to assist in the distribution of the various copies.

The copies 30 of each of the duplicate form sets 28 have a generally rectangular form with the edge of one of the short sides disposed between the tabs 20 and 24. The tabs 20 and 24 and the edges of each of the duplicate order copies contained therein are connected to one another by a suitable adhesive. The edge of the duplicate order copy 30 associated with the tabs 20 and 24 may be separated from the body of the order copy along a perforated line 32. The only physical connection of the order copies 30 with the assembly is with the tabs 20 and 24. This connection with the tabs is suflicient to maintain the printed matter on the duplicate order copies '30 aligned with the printed matter in order sections 18 on the face sheet 12.

The short end of each of the duplicate order copies 30 opposite the tabs 20 and 24 is dimensioned such that it is spaced from the fold line 18-. This spacing of the duplicate order copies from the fold line is snfiicient that the user may impose a gripping elfort on the face sheet 12 and the backing sheet 14 without engaging the edge of the duplicate order copies 30.

Referring to FIG. 3, when the physician has written a prescription on one of the order sections .18 so that a reproduction of the prescription has been produced on the individual copies of the duplicate order form 28, the order form is removed from the order form assembly by gripping the face sheet and the backing sheet. 14 along their fold line 10 so that the duplicate form set 28 is not engaged, imposing a gripping effort on the tabs associated with the order, and snapping the tabs with the order form set away from the assembly. Thus the tab 20 is separated from the face sheet 12 along the perforated line 22 and the tab 24 is separated from the backing sheet 14 along the perforated line 26. The tabs 20 and 24 are simultaneously separated from the assembly to remove the duplicate form set 28 from between the face sheet 12 and the backing sheet 14.

The perforated line 32 joining the edge of the duplicate order copies 30 between the tabs 20 and 24 and the bodies of the order copies is of a strength suflicient to Withstand any frictional forces imposed on the duplicate form set 28 as it is withdrawn from between the face sheet 12 and the backing sheet 14. That is to say that when the form set 28 is withdrawn from the assembly, the body of each of the order copies 30 remains attached with their leading edge. When the duplicate form set 28 has been entirely removed from between the face sheet 12 and the backing sheet 14, the order form copies 30' are individually separated from the tabs for distribution. When each of the duplicate form sets 28 has been filled and all have been removed from the order form assembly, the backing sheet 14 is separated along the fold line from the face sheet 12 to reduce the amount of paper retained as a permanent record.

The duplicate copies 30 are each preferably provided adjacent their upper long edge with a pressure sensitive tape (not shown). Upon separation from the set, each copy is individually attached to a file record or other article with which they are associated. For instance, the pharmacist, upon filling the prescription, attaches one of the copies to the medicine by removing the pressure sensitive tape from the copy which then is stuck to the con tainer holding the medicine.

It can be seen that the combination of the tabs and the tabs 24- which retain therebetween the duplicate form set 28 and which are separable from the assembly along a relatively short perforated line enables the order copies to be efficiently and clearly separated from the order form assembly. Because of this relatively clean separation of the copies of the medication order from the original medication order, the problem encountered in order form assemblies of the prior art of the copies of the prescription order tearing as they are separated from one another has been eliminated.

It is to be understood from the foregoing description that various changes and modifications may be made without departing from the spirit of the invention or the scope of the appended claims.

I claim:

1. A blank form assembly useful as a medication order form in hospitals and the like, comprising:

(a) a face sheet having areas with printed matter as well as blank areas to be filled in with special matter;

(b) a backing sheet underlying said face sheet and generally coextensive therewith, and said backing sheet joined to said face sheet along a common edge of.

joinder;

(c) a plurality of face sheet tabs forming extensions along an edge of said face sheet and each of said tabs joined to said face sheet by a weakened line of separation;

(d) a plurality of backing sheet tabs forming extensions along an edge of said backing sheet corresponding to the tab supporting edge of said face sheet and each of said backing sheet tabs associated with one of the face sheet tabs and joined to said backing sheet by a weakened line of separation coinciding with the line of separation of the corresponding face sheet tab;

(e) a duplicate sheet associated with each of said face sheet tabs and formed of a rectangular sheet material capable of producing visible indicia on said duplicate when discrete areas thereof are subjected to a pressure such as by that produced by a writing pen, said duplicate sheet disposed interjacent said face sheet and said backing sheet and underlying the blank areas of said face sheet to be filled in with special matter, said duplicate sheet joined for removable attachment to said tabs, and having its perimetric edge spaced from the common edge of joined of said face sheet and said backing sheet so that said duplicate sheet may be snapped out from said assembly by applying a gripping effort to said face sheet and said supporting sheet along a common edge and a second gripping effort to the tabs associated with said duplicate sheet so that the tabs may be separated from the face and backing sheets along associated lines of separation without separation from said duplicate sheet.

2. The invention as defined in claim 1 wherein said face sheet is integrally connected for separation to said backing sheet along said common edge of joinder by a weakened lines of separation.

3. The invention as defined in claim 1 wherein said face sheet and said backing sheet have a rectangular outline and are joined for separation to one another along a common long edge.

4. The invention as defined in claim 3 wherein said tabs form extensions of said face sheet and said supporting sheet along the long edge opposite the long edge joining said sheets.

5. The invention as defined in claim 1 including a plurality of said duplicate sheets associated with each of said tabs and each of said duplicate sheets has a similar rectangular outline with a short edge associated with said tabs, and the length of said duplicate sheets dimensioned so that the opposite short edge is spaced from the common edge of joinder of said face sheet and said backing sheet.

6. The invention as defined in claim 1, wherein said duplicate sheets have a rectangular outline with one short edge associated with said tabs and the other short edge spaced from the common line of joinder of said face sheet and said backing sheet, and wherein the long edges of the duplicate sheet associated with each tab are spaced from the long edges of the duplicate sheet of the adjacent tab. 7. The invention as defined in claim 1 wherein the common edges of joinder of the face sheet and the backing and the common edge where said gripping effort is applied is the same.

References Cited by the Examiner UNITED STATES PATENTS 1,980,319 11/1934 Caton 282-22 2,314,495 3 1943 Hall 2828 2,448,143 8/1948 Gilbert 2828 LAWRENCE CHARLES, Primary Examiner. 

1. A BLANK FROM ASSEMBLY USEFUL AS A MEDICATION ORDER FORM IN HOSPITALS AND THE LIKE, COMPRISING: (A) A FACE SHEET HAVING AREAS WITH PRINTED MATTER AS WELL AS BLANK AREAS TO BE FILLED IN WITH SPECIAL MATTER; (B) A BACKING SHEET UNDERLYING SAID FACE SHEET AND GENERALLY COEXTENSIVE THEREWITH, AND SAID BACKING SHEET JOINED TO SAID FACE SHEET ALONG A COMMON EDGE OF JOINDER; (C) A PLURALITY OF FACE SHEET TABS FORMING EXTENSIONS ALONG AN EDGE OF SAID FACE SHEET AND EACH OF SAID TABS JOINED TO SAID FACE SHEET BY A WEAKENED LINE OF SEPARATION; (D) A PLURALITY OF BACKING SHEET TABS FORMING EXTENSIONS ALONG AN EDGE OF SAID BACKING SHEET CORRESPONDING TO THE TAB SUPPORTING EDGE OF SAID FACE SHEET AND EACH OF SAID BACKING SHEET TABS ASSOCIATED WITH ONE OF THE FACE SHEET TABS AND JOINED TO SAID BACKING SHEET BY A WEAKENED LINE OF SEPARATION COINCIDING WITH THE LINE OF SEPARATION OF THE CORRESPONDING FACE SHEET TAB; (E) A DUPLICATE SHEET ASSOCIATED WITH EACH OF SAID FACE SHEET TABS AND FORMED OF A RECTANGULAR SHEET MATERIAL CAPABLE OF PRODUCING VISIBLE INDICIA ON SAID DUPLICATE WHEN DISCRETE AREAS THEREOF ARE SUBJECTED TO A PRESSURE SUCH AS BY THAT PRODUCED BY A WRITING PEN, SAID DUPLICATE SHEET DISPOSED INTERJACENT SAID FACE SHEET AND SAID BACKING SHEET AND UNDERLYING THE BLANK AREAS OF SAID FACE SHEET TO BE FILLED IN WITH SPECIAL MATTER, SAID DUPLICATE SHEET JOINED FOR REMOVABLE ATTACHMENT TO SAID TABS, AND HAVING ITS PERIMETRIC EDGE SPACED FROM THE COMMON EDGE OF JOINED OF SAID FACE SHEET AND SAID BACKING SHEET SO THAT SAID DUPLICATE SHEET MAY BE SNAPPED OUT FROM SAID ASSEMBLY BY APPLYING A GRIPPING EFFORT TO SAID FACE SHEET AND SAID SUPPORTING SHEET ALONG A COMMON EDGE AND A SECOND GRIPPING EFFORT TO THE TABS ASSOCIATED WITH SAID DUPLICATE SHEET SO THAT THE TABS MAY BE SEPARATED FROM THE FACE AND BACKING SHEETS ALONG ASSOCIATED LINES OF SEPARATION WITHOUT SEPARATION FROM SAID DUPLICATE SHEET. 